JAMA Forum: Transforming the Costly Travesty of US Maternity Care

Despite some progress in maternal-newborn care, such as a decrease in the rate of premature birth, the United States continues to perform poorly on some important quality and cost indicators. Cesarean delivery is now the most common operating room procedure in the United States. The US rate of cesarean deliveries, an appalling 33%, increased 53% between 1997 and 2009.

Despite our current spending on birthing care, the United States ranks 46th in the world on maternal mortality—with a rate that has doubled since 1987 and is twice that of 31 other nations. Even our infant mortality rate, at 6.1 deaths per 1000 live births, puts the United States 32nd of 34 other nations that belong to the Organization for Economic Co-operation and Development. And for both maternal and infant mortality, racial and ethnic disparities persist.

Why Are We Not Doing Better?

Improving maternal-newborn outcomes while reducing costs is within our reach. What stands in the way? Here are 4 factors.

1. Service Design. We need to question the basic framework for designing maternity services: should it be one in which pregnancy and birth are viewed as normal life transitions or as diseases? This is not just a philosophical issue. The midwifery model of care views birthing as a normal physiologic process and involves care that includes the identification of women at risk for complications and in need of management by an obstetrician.

The American Association of Birth Centers has identified more than 250 freestanding US birth centers that use such a framework. They rely on certified and licensed midwives, including nurse-midwives to “attend” the births (the midwifery framework argues that the mother—not the provider—delivers the baby with the support of the professional), with physician and hospital back-up as needed. The excellent outcomes of these birth centers and midwife-led care have been documented in a Cochrane Collaboration systematic review and the National Birth Center Study.

2. Payment. A 2010 companion document, “Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System,” advocates payment reform that would encourage hospitals and professionals to decrease the use of unnecessary procedures while providing evidence-based care. These reforms ought to include bundling payments that are linked with quality outcomes, withdrawing incentives for inappropriate care, and paying birth centers at 100% of the rate of hospitals for the same or equivalent codes, such as for normal vaginal delivery.

Some private payers still won’t pay for childbearing at a birth center, despite the evidence that doing so improves outcomes and costs. Kitty Ernst, CNM, MPH, the Mary Breckinridge Chair of Midwifery at the Frontier Nursing University, in Hyden, Kentucky, and one of the pioneers of the birth-center movement, told me that employers can and have changed this: “All health insurance programs [should] be required to pay for evidence-based care during the childbearing years in order to be licensed to do business. We are an employer-based private health insurance country. Does your employer know about the cost savings of alternative care? Childbirth constitutes the highest payout for many employer insurance plans.”

Nor are Medicaid managed care plans required to share savings. In 2009, when Bellevue Hospital closed the only birth center in New York City that still accepted Medicaid, I asked a member of the board of trustees of Health and Hospital Corporation, the umbrella for the city’s public hospitals, why they would close it, given the savings it generated. The trustee answered: “Because it doesn’t save Bellevue money. It saves Medicaid money.”Currently, the only way for a birth center to receive some of that savings is to negotiate shared savings as part of its contract with the Medicaid Managed Care Organization or to push the state to require it. An increasing number of states are setting up accountable care organizations within their Medicaid programs. Accountable care organizations provide opportunities to develop new models for shared savings with birth centers.

3. Workforce Development. The consensus documents call for aligning the childbirthing workforce with the needs of pregnant women—a largely healthy population that needs few procedures or technological interventions. Maternity services should be provided by certified and licensed midwives and family physicians, reserving highly trained obstetricians for the high-risk pregnancies. This requires that we invest more in the education of midwives and family physicians.

But this will not guarantee that those who receive such education could practice to the full extent of their training or that they would remain in practice. Consider these barriers to maternity service providers:

Until the Affordable Care Act (ACA) was enacted, nurse midwives were paid 65% of the Physician Fee Schedule under Medicare. The ACA changed this to 100% but didn’t include certified midwives who are not nurses.

In some states, certified nurse midwives are required to be supervised by a physician, and other states do not permit certified midwives to practice.

4. Investment. Public and private capital investments will be needed to expand birth centers to the frontlines of maternity care in all communities. Women should have a choice of where they receive perinatal care, including where they deliver.

This choice is already provided at the Family Health and Birthing Center (FHBC) of Washington, DC. The FHBC is part of the Developing Families Center, founded by Ruth Watson Lubic, CNM, EdD, and Linda Randolph, MD, as a comprehensive provider of family-centered women’s and children’s care, family resource and support services, confidential counseling, and adult education. Unlike many other birth centers, this one serves mostly poor African American families in the shadow of the nation’s Capitol. The FHBC’s care model goes beyond the care recommended in the consensus reports; it focuses on providing families with a healthy start through perinatal care, family health services, and early childhood development.

Investing in such a model could do more than improve birthing outcomes. It could strengthen families and communities in ways that could improve other health indicators.

Maternal-newborn care is one of 10 Essential Health Benefits that insurance plans must include under Medicaid and state or federal health exchanges beginning in 2014. This is expected to provide 8.7 million more women with maternity coverage.

Funding is included for home visitation programs for first-time pregnant women at high risk for poor outcomes. The model of home visits, usually provided by nurses or social workers, builds on the success of the Nurse-Family Partnership in improving short-term and long-term health and social outcomes for mothers and children, at a significant cost savings.

Childbirth Connection, the American College of Obstetricians, and the American Medical Association have identified the services that should be in health plans the states offer through their health exchanges. But because states are not required to include all of these services, we need a more comprehensive policy and service approach.

Ernst told me that the “regulatory and payment systems have been impediments to the collaboration and continuity of care [that are] essential [for] improving the birth experience of the woman and her family.” As our nation strives to achieve the “triple aim” of better health, better care experiences, and lower costs, redesigning maternity services should be at the top of our list of reforms.

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About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.

About The JAMA Forum:JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.